Hypoproteinemia predicts disease severity and mortality in COVID-19: a call for action.

Proteins represent the major building blocks of body tissues, and they regulate signaling involved in most cellular activities. Coronavirus disease 2019 (COVID-19) infection has been associated with high fatality, especially among older adults. The main cause of death is pulmonary tissue damage and multiple organ failure. The disease is associated with a hypercatabolic state that entails excessive protein loss. This review commentary sheds the light on hypoproteinemia in symptomatic/hospitalized COVID-19 with a special emphasis on its pathophysiology, screening, as well as its contribution to disease severity and adverse effects.

Concurrent minimal change disease and retroperitoneal liposarcoma successfully treated by tumor resection and steroid therapy.

A 54-year-old Japanese woman developed simultaneous abdominal distension and bilateral leg edema. Her medical history and results of periodic medical check-up were unremarkable. Blood tests revealed severe hypoproteinemia and acute kidney injury, and urinalysis revealed 4+ proteinuria and 2+ hematuria. Abdominal computed tomography revealed a large intra-abdominal mass with fat tissue density. She underwent emergency tumor excision, splenectomy, and distal pancreatectomy. However, hypoproteinemia and acute kidney injury worsened. Therefore, she was transferred to the nephrology division for confirmation of diagnosis and for treatment of acute kidney injury and nephrotic syndrome. We conducted percutaneous kidney biopsy and diagnosed minimal change disease (MCD). Intravenous prednisolone was started, and heavy proteinuria and systemic edema were gradually alleviated. She achieved complete remission 2 months later, and oral prednisolone was tapered. Histopathological diagnosis of abdominal tumor was dedifferentiated liposarcoma of retroperitoneal origin. Immunohistochemical staining revealed strong expression of vascular endothelial growth factor in the tumor cells in the dedifferentiated component. Currently, her clinical course is stable without recurrence of liposarcoma and nephrotic syndrome. MCD develops in patients with Hodgkin's lymphoma, solid organ cancers, hematological malignancies, and thymoma, whereas concurrent MCD and liposarcoma are rare. Remission of nephrotic syndrome and normalized kidney function induced by steroid therapy are important for better management of patients with malignancy.

Clinical Characteristics and Analysis of Lung Cancer- Associated Acute Ischemic Stroke.

INTRODUCTION: The incidence of lung cancer and acute ischemic stroke remains high in recent years, both of which occur mostly in people over 60 years old. In the present study, we aimed to further clarify the pathogenesis of lung cancer-associated acute ischemic stroke (LCA-AIS) by comparing and analyzing clinical characteristics of stroke patients with or without lung cancer. METHODS: A total of 51 patients with lung cancer were selected as the case group (LCSG), and 78 patients without cancer history were adopted as the control group (SG). The data collected in this study included sex, age, traditional cerebrovascular disease risk factors (TCDRFs), blood test index, imaging findings, etiological typing, and prognosis evaluation. SPSS21.0 software was used for statistical analysis. Normally distributed data were analyzed by t-test, and count data were analyzed by chi-square test or exact probability method. P < 0.05 was considered statistically significant. RESULTS: In the case group, the levels of plasma D-dimer, fibrinogen degradation products (FDPs) and NIHSS, as well as the mRS score and mortality of patients, were higher, while the levels of RBC, Hb and Hcy were lower compared with the control group. Imaging findings showed that multivessel involvement was more common in the case group, and the infarcts were more likely to be multiple and involved in both the anterior and posterior circulations. The TOAST classification of LCSG was dominated by stroke of undetermined etiology (SUE) and stroke of other determined etiology (SOE). Statistical analysis showed that the patients were more likely to suffer from acute ischemic stroke within 1 year after the diagnosis of lung cancer (41 cases, 80.39%). CONCLUSIONS: Hypercoagulability and acute multiple brain infarcts were more common in patients with LCA-AIS, and hypoproteinemia and hyponatremia were more likely to occur in these patients, leading to worse prognosis. Patients were most likely to have a stroke within 1 year after the diagnosis of lung cancer.

Hypoalbuminemia-Related Prolonged Sedation After General Anesthesia: A Case Report.

A 69-year-old man underwent total laryngopharyngectomy with radial forearm free flap reconstruction. He had lost 15 kg over a period of 6 months and did not receive any preoperative nutritional workup or management. The patient had a general total intravenous anesthetic with ketamine, lidocaine, and propofol, which was uneventful for an 8-hour surgery. The patient remained deeply sedated for 4 hours after discontinuation of all sedative medications. Diagnostic workup only revealed hypoalbuminemia and hypoproteinemia. We hypothesized relative overdosage of sedative anesthetic drugs due to preoperative malnutrition accentuated by intraoperative fluid administration.

Protein losing gastroenteropathy due to Helicobacter pylori infection without giant rugal folds, erosion or polyposis.

An 85-year-old woman was admitted to our hospital because of progressive hypoproteinemia and generalised oedema. Technetium-99m human albumin scintigraphy revealed protein leakage in the gastrointestinal tract. Upper gastrointestinal endoscopy revealed small whitish nodules from the gastric body up to the duodenal bulb. The urease test for Helicobacter pylori infection was positive. We diagnosed her as having protein-losing gastroenteropathy (PLGE) caused by H. pylori infection. The patient's hypoproteinemia and clinical symptoms promptly resolved after H. pylori eradication. Our results suggest that a trial of H. pylori eradication is warranted in patients with PLGE, even if endoscopy reveals neither giant rugal folds, erosion of the mucosa, nor polyposis, which are previously reported characteristic endoscopic findings of PLGE.

Prevalence of Clinically Significant Differences in Sodium Measurements Due to Abnormal Protein Concentrations Using an Indirect Ion-Selective Electrode Method.

BACKGROUND: Indirect ion-selective electrode (ISE) is the primary method used to measure sodium in automated clinical laboratories and is susceptible to the electrolyte exclusion effect. Pseudohyponatremia due to hyperproteinemia can affect patient management. The aims of this study were to (a) establish the relationship between serum total protein (TP) concentration and the magnitude of the electrolyte exclusion effect on indirect ISE-measured sodium values (b) estimate the frequency at which TP concentrations outside the reference interval may impact indirect-ISE measured sodium values, and (c) determine whether clinical decision support (middleware) rules in the laboratory would be effective for detecting cases of pseudohyponatremia. METHODS: Residual waste serum specimens from physician-ordered TP testing were collected (n = 112). Sodium concentration was measured using indirect ISE (Cobas 8000, Roche Diagnostics) and direct ISE (ABL 825, Radiometer) methods. The difference in sodium concentration (Δ[Na+]) was calculated as follows: ([Na+]indirect-ISE - [Na+]direct-ISE). Retrospective TP results reported from July 31, 2013, to September 24, 2014, were stratified by ordering location and sodium and TP co-ordering rates were quantified. RESULTS: Δ[Na+] was inversely proportional to TP concentration (y = -1.29x + 8.6, R = -0.883). The average difference (SD, range) was -6.1(3.4, -16-0) mmol/L when TP >7.9 g/dL (>79g/L), with 69% of samples demonstrating differences ≥4.0 mmol/L. A majority of intensive care unit patients (81%) were hypoproteinemic (<6.3 g/dL, <63g/L). Only 10.9% of sodium test orders include an order for TP on the same collection. CONCLUSIONS: Indirect sodium measurement is impacted when TP concentrations are increased. TP concentration outside the reference interval is prevalent and sodium is usually not ordered with TP. Health systems need to be aware of the limitations of their indirect-ISE method for sodium measurement.

Hypoproteinemia as a factor in assessing malnutrition and predicting survival on hemodialysis.

Series of studies have described malnutrition as one of the main non-traditional risk factors associated with poor prognosis and treatment outcome in patients on hemodialysis (HD). The aims of this study were to evaluate the link between HD treatment quality and the nutritional status and to additionally investigate the association of malnutrition and overall survival. A total of 134 adult out-patients (56.4% male, mean age 60.8 ± 16.15 years) were enrolled in the study. Clinical and laboratory data were obtained from the medical records. Anthropometric measurements were performed prior to HD. Malnutrition-Inflammation Score (MIS) was used as a scoring system representing the severity of protein-energy wasting (PEW). Malnourished patients were significantly older when compared to non-malnourished patients. They had significantly longer dialysis vintage and lower residual diuresis, BMI, serum proteins, and albumins and lean tissue index (LTI). Malnourished patients survived significantly shorter than non-malnourished patients. Hypoproteinemic patients had significantly lower values of serum albumins and LTI and survived shorter than normoproteinemic patients. Only malnourishment and age were associated with higher overall mortality in all groups of patients. By focusing on MIS and serum protein status rather than dialysis-related factors and different treatment techniques, we could accomplish better nutrition status and improved overall outcomes. While anticipating new and more effective measures for preventing malnutrition, our results clearly demonstrate that striving for the highest possible nutrition status should be one of the key strategies in improving the outcomes in this specific group of patients.

Collagenous gastritis: An unusual cause of generalized oedema in a child.

Collagenous gastritis is an uncommon gastrointestinal disease in children. Its cause remains uncertain. It may present as severe hypoproteinaemia manifesting as generalized oedema. We report a 15 months old female who presented with pica, generalized body oedema and diarrhoea. Diagnostic workup revealed gastric replacement of the lamina propria by hyalinized collagen on histology. This case seeks to highlight the need for early paediatric gastroenterology referral including oesophagogastroduodenoscopy with multiple tissue biopsies as part of a broad diagnostic workup in children with non-specific gastrointestinal symptoms to improve diagnostic yield and enable accurate histologic diagnosis, so that appropriate therapy can be timeously applied.

Low Plasma Protein Levels at Birth Are Associated with Poor Cardiovascular Adaptation and Serious Adverse Outcome in Infants with Gestational Age <32 Weeks: The ProHémie Study.

BACKGROUND: Retrospective studies suggest that early hypoproteinemia has prognostic value for adverse outcome in preemies, but the underlying pathophysiology is unknown. We hypothesized that the prognostic relevance of hypoproteinemia could be related to its association with impaired cardiovascular function and organ perfusion during transition. OBJECTIVES: To describe the plasma protein status and the measures of cardiovascular function according to the outcome in infants <32 weeks' gestation. METHODS: One hundred and twenty-eight infants were prospectively included from birth to discharge. During the first 24 h of life, we assessed the cardiovascular function and systemic and organ blood flow by Doppler ultrasound, and monitored cerebral and renal regional oxygen saturation (cRSO2, rRSO2) using near-infrared spectroscopy. These measures were analyzed in relationship to hypoproteinemia (total plasma protein level <40 g/L at 12 h of life) and severe adverse outcome (death or survival with severe neurological injury). RESULTS: Hypoproteinemia was associated with a higher risk of a severe adverse outcome after adjustment of confounding variables (adjusted OR = 6.8; 95% CI 1.3-34). Compared to normoproteinemic infants and after adjustment for gestational age, hypoproteinemic ones had more significantly: hypotension (7 vs. 13%, p = 0.03), abnormal capillary refilling time (20 vs. 36%, p < 0.001), abnormal renal blood flow (resistive index 0.78 ± 0.11 vs. 0.85 ± 0.09, p = 0.04), lower rRSO2 (82.9 ± 9.2 vs. 73.6 ± 10.5%, p = 0.04), and lower systemic vascular resistance (0.155 ± 0.058 vs. 0.108 ± 0.037 mm Hg/L/kg; p = 0.04). The cRSO2 patterns were significantly decreased in infants with severe adverse outcome and independent from protein status. CONCLUSION: Hypoproteinemia is associated with impaired cardiovascular function. Further studies are required to elucidate the interplay between changes in protein levels, postnatal hemodynamics and clinical outcome.

[Protein-losing enteropathy]. / Enteropatiya s poterei belka.

Protein-losing enteropathy (PLE) is a rare complication of intestinal diseases. Its main manifestation is hypoproteinemic edema. The diagnosis of PLE is based on the verification of protein loss into the intestinal lumen, by determining fecal α1-antitrypsin concentration and clearance. The localization of the affected colonic segment is clarified using radiologic and endoscopic techniques. The mainstay of treatment for PLE is a fat-free diet enriched with medium-chain triglycerides. Surgical resection of the affected segment of the colon may be the treatment of choice for severe hypoproteinemia resistant to drug therapy.

Correlations between the levels of acute infection markers and serum albumin in elderly patients with hip fracture.

OBJECTIVE: The aim of this study was to explore a clinical index that could predict the decline of serum albumin (ALB) in elderly patients (over 60 years old) with hip fractures in 2014. METHODS: All the data came from the retrospective survey, and the correlations between the ALB changes and acute infection markers were then analyzed using correlation analysis. The changes of infection markers and ALB before and after surgery were compared using the t test. RESULTS: There was no correlation of the serum ALB blood with interleukin-6 (IL-6) (r = 0.072, P = 0.588), C-reactive protein (CRP) (r = -0.249, P = 0.057), or calcitonin (PCT) (r = -0.038, P = 0.775) when patients were admitted, but it was negatively correlated with the total amount of infection markers (TAIMs) (r = -0.301, P = 0.020). The postoperative levels of IL-6 (154.23 ± 177.14 pg/mL) (P < 0.001), CRP (69.52 ± 39.84 mg/L) (P < 0.001), and PCT (1.27 ± 2.4 ng/mL) (P < 0.001) were significantly increased than those before surgery [IL-6 (44.96 ± 54.58 pg/mL), CRP (31.78 ± 29.90 mg/L), and PCT (0.42 ± 1.06 ng/mL)]. The postoperative level of serum ALB (29.93 ± 3.02 g/L) was significantly reduced than that before surgery (33.95 ± 3.69 g/L) (P < 0.001). The serum ALB level was negatively correlated with IL-6 (r = -0.333, P = 0.015) before surgery, but not correlated with TAIMs (r = -0.256, P = 0.061). The serum ALB level was negatively correlated with IL-6 (r = -0.292, P = 0.034) and TAIMs (r = -0.271, P = 0.050) after surgery. CONCLUSIONS: The serum IL-6 level could predict the changes of ALB during the disease process.

The Impact of Protein Nutritional Supplementation for Massive Weight Loss Patients Undergoing Abdominoplasty.

BACKGROUND: As more patients undergo bariatric surgery to assist with weight loss, the demand for post-bariatric body contouring surgery, to address both functional and aesthetic concerns, is increasing. However, high wound healing complication rates remain a significant problem for these patients. One theory is that chronic malnourishment and hypoproteinemia may contribute significantly to these wound healing complications. OBJECTIVE: The purpose of this study was to determine the effect of pretreatment protein nutritional supplementation on wound healing in post-bariatric surgery massive weight loss patients undergoing abdominoplasty. Our hypothesis was that protein supplementation would decrease wound healing complications. METHODS: A retrospective review was performed of 23 post-bariatric surgery patients undergoing abdominoplasty who received pretreatment protein nutritional supplementation. This group was compared with a historical control group of 23 post-bariatric surgery patients who underwent abdominoplasty in the period immediately before the implementation of the protein supplementation protocol. Patient demographics and procedural characteristics were similar for the two groups. RESULTS: Forty-six patients were identified who had undergone abdominoplasty, half of whom were prescribed the protein supplementation protocol. Overall wound healing complication rates were significantly lower in the protein-supplemented group (0.0% vs. 21.8%, p = 0.04). There was no significant difference between the protein supplementation and historical control groups in regards to total complication rate. CONCLUSIONS: Pretreatment protein supplementation is a simple intervention that can significantly decrease wound healing complications in post-bariatric surgery massive weight loss patients undergoing abdominoplasty. LEVEL OF EVIDENCE 4: Therapeutic.

The first report of adolescent TAFRO syndrome, a unique clinicopathologic variant of multicentric Castleman's disease.

BACKGROUND: TAFRO syndrome is a unique clinicopathologic variant of multicentric Castleman's disease that has recently been identified in Japan. It is characterized by a constellation of symptoms: Thrombocytopenia, Anasarca, reticulin Fibrosis of the bone marrow, Renal dysfunction and Organomegaly (TAFRO). Previous reports have shown that affected patients usually respond to immunosuppressive therapy, but the disease sometimes has a fatal course. TAFRO syndrome occurs in the middle-aged and elderly and there are no prior reports of the disease in adolescents. Here we report the first adolescent case, successfully treated with anti-IL-6 receptor antibody (tocilizumab, TCZ) and monitored with serial cytokine profiles. CASE PRESENTATION: A 15-year-old Japanese boy was referred to us with fever of unknown origin. Whole body computed tomography demonstrated systemic lymphadenopathy, organomegaly and anasarca. Laboratory tests showed elevated C-reactive protein and hypoproteinemia. Bone marrow biopsy revealed a hyperplastic marrow with megakaryocytic hyperplasia and mild reticulin fibrosis. Despite methylprednisolone pulse therapy, the disease progressed markedly to respiratory distress, acute renal failure, anemia and thrombocytopenia. Serum and plasma levels of cytokines, including IL-6, vascular endothelial growth factor, neopterin and soluble tumor necrosis factor receptors I and II, were markedly elevated. Repeated weekly TCZ administration dramatically improved the patient's symptoms and laboratory tests showed decreasing cytokine levels. CONCLUSION: To our knowledge, this is the first report of TAFRO syndrome in a young patient, suggesting that this disease can occur even in adolescence. The patient was successfully treated with TCZ. During our patient's clinical course, monitoring cytokine profiles was useful to assess the disease activity of TAFRO syndrome.

Cap-polyposis-like gastropathy with hypoproteinemia treated with H. pylori eradication.

We herein report the case of a 43-year-old man with distinct gastropathy and hypoproteinemia treated with H. pylori eradication therapy. Most reported cases of protein-losing gastropathy are divided into Ménétrier's disease (MD) and diffuse varioliform gastritis (DVG). Our patient presented with leg edema due to marked hypoalbuminemia, which we ascribed to distinct gastropathy with novel endoscopic findings resembling cap polyposis in the colon, apparently different from both MD and DVG. H. pylori eradication therapy promptly induced the normalization of laboratory data and mucosal healing. Our case together with two previously published similar cases may contribute to establishing an association between cap-polyposis-like-gastropathy with hypoproteinemia and H. pylori.

Afectación del sistema nervioso central y periférico en la fascitis eosinofílica / Central nervous system involvement on eosynophillic fascitis

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